In the 1950s, 558,000 people were in mental institutions in the U.S. Many were there against their will and were being warehoused or treated badly. Deinstitutionalization was intended to restore their civil rights and improve their lot. Did it? By 2006, there were only 40,000 people in institutions. What happened to the other 518,000?

Some of them are living in the community with supportive family members, taking their medications, and contributing to society. Some of them have been ghettoized in halfway houses or group homes in crime-ridden and run-down neighborhoods. Some of them are homeless, living on the streets and eating out of garbage cans. Some of them are in jail. Some of them have killed family members or have killed multiple people in “rampage” murders provoked by their psychotic delusions.

Accurate numbers are difficult to obtain. By some estimates, as many as 30-50% of the homeless (and even more of the hard-core homeless) and as many as 40-50% of the jail population are mentally ill. There are more mentally ill people in jails than in hospitals. The mentally ill are more likely to be victims of violence and rape and are more likely to be shot by the police in “justifiable homicide” incidents.

Mentally ill people who are adequately treated are no more violent than the non-mentally ill, but a disproportionate number of murders are committed by the mentally ill. The risk of violence increases with past history of violence, substance abuse, anosognosia with medication noncompliance, antisocial personality disorder, paranoid symptoms, and male sex.

Civil rights advocates argue that patients with other illnesses like heart disease or cancer have the right to refuse treatment – but those patients presumably are capable of understanding that they are ill. About half of psychotic patients are incapable of understanding that they are ill – the lack of insight or anosognosia is part of their disease, similar to the anosognosia of a stroke patient whose brain damage makes him unable to recognize that he is paralyzed on one side. If you truly believe you are God, you’re not about to let anyone give you pills intended to make you think otherwise. If you can’t recognize that you are ill, why would you accept treatment for a condition you firmly believe you do not have? Are we really giving these patients their civil rights, or are we denying them their right to be treated?

There is precedent for involuntary treatment – TB patients are a prime example. If they refuse medication or take it inconsistently they are putting their communities at risk, so the courts allow compulsory treatment under direct supervision. The Virginia Tech shooter had been hospitalized after harassing two female students and was under court order to get outpatient treatment; the University knew about the court order but did not enforce it. We can never know for sure, but there is a good chance that if he had been forced to take antipsychotic medication his 32 victims would still be alive.

It has become next to impossible to get a patient involuntarily committed. You have to show that they are an immediate danger to themselves or others. When they are committed, the typical course is that they are given medication, their symptoms subside, they are discharged, they go off their meds, and the symptoms recur. One police officer described picking up the same woman and taking her to the hospital 16 times for lying down in the street.

To put a human face on the dilemma, imagine you are the parent of a paranoid schizophrenic who has been repeatedly hospitalized and jailed, whose psychotic symptoms disappear when he takes his meds but who refuses to take them. He has repeatedly threatened to kill you and other family members, saying God wants him to root out the evil. You awaken in the middle of the night to find him hovering menacingly over your bed. He sleeps with an ax. He regularly gets drunk and disorderly. He has battered down the door of your apartment in the middle of the night, causing your landlord to evict you. You are desperately afraid for your life and for the lives of your family members. You have repeatedly pleaded with police and mental health authorities for help, and all they do is tell you to make him take his meds – which you can’t do. Society will do nothing to help you until he actually hurts someone. Families have even moved out and left the house to the mentally ill person, but it did no good – he followed them. One woman had a psychotic brother who had repeatedly threatened to kill her only daughter; she believed the threats and was desperate to save her daughter’s life. After years of fruitlessly begging for help from every available resource, she ran out of options, killed her brother and went to jail for murder. Imagine pleading repeatedly and unsuccessfully with the authorities to get treatment for your wife and coming home to find she has killed all your children because Satan told her to. Imagine begging authorities for help because your son has threatened his mother, being told he does not meet the criteria for involuntary commitment, and then coming home to find he has beaten his mother to death.

Yes, mentally ill people have civil rights, but so do their families and other victims. There are effective, humane programs for outpatient treatment of the mentally ill, and some have ingenious incentive programs to increase medication compliance. Unfortunately, these programs only reach a tiny fraction of the patients at risk. And unfortunately, it is the most dangerous patients who are the least likely to recognize that they are ill and the most likely to refuse treatment. Surely as a society we can do more to help these unfortunate patients and their just-as-unfortunate families and victims.

Perhaps it is wrong to confine patients against their will. But, as Supreme Court Justice Anthony Kennedy said,

It must be remembered that for the person with severe mental illness who has no treatment, the most dreaded of confinements can be the imprisonment inflicted by his own mind, which shuts reality out and subjects him to the torment of voices and images beyond our powers to describe

One of the creators of a strict state statute later said,

I wanted the LPS act to help the mentally ill. I never meant for it to prevent those who need care from receiving it. The law has to be changed.

To quote Stephen Rachlin,

The paramount civil right of the patient should be that of adequate treatment.

We are abandoning sick patients to live on the streets, forage from garbage cans, and bounce in and out of jail, and we are exposing our society to unnecessary violence. Surely we can do better.

For further reading:
The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers its Citizens, by E. Fuller Torrey.
There is a well-balanced editorial in the New England Journal of Medicine A recent review of violence and mental illness
An article on poor insight in schizophrenia and its effect on compliance.

Posted by Harriet Hall

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly.